Information Collection

Original Cohort Forms

IC 7259 under ICR 201309-0925-008 · OMB 0925-0216.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0216 can be found here:

Documents and Forms

Document Name Document Type
Form A7a Original Cohort Forms Form and Instruction
A7a Telephone Call to Set up Meeting Attachment 7a- Telephone Contact.pdf Form and Instruction
A4 Medical Status Update Form Attachment 4 - Medical Hx Update Form.pdf Form and Instruction
A7b Exam Scheduling Form Attachment 7b- Exam Scheduling.pdf Form and Instruction
A2a Clinical Exam Form -Original Attachment 2a - Clinic Exam, Original.pdf Form and Instruction
A6a Records Request Form Attachment 6a- Records Request.pdf Form and Instruction
A2b Home Visit form-Original Attachment 2b- Home Visit, Original.pdf Form and Instruction
A6b Informant Contact Form Attachment 6b- Informant Contact.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Original Cohort Forms	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	A7a	Telephone Call to Set up Meeting	Attachment 7a- Telephone Contact.pdf	Yes	Yes	Paper Only
Form and Instruction	A4	Medical Status Update Form	Attachment 4 - Medical Hx Update Form.pdf	Yes	Yes	Paper Only
Form and Instruction	A7b	Exam Scheduling Form	Attachment 7b- Exam Scheduling.pdf	Yes	Yes	Paper Only
Form and Instruction	A2a	Clinical Exam Form -Original	Attachment 2a - Clinic Exam, Original.pdf	Yes	Yes	Paper Only
Form and Instruction	A6a	Records Request Form	Attachment 6a- Records Request.pdf	Yes	Yes	Paper Only
Form and Instruction	A2b	Home Visit form-Original	Attachment 2b- Home Visit, Original.pdf	Yes	Yes	Paper Only
Form and Instruction	A6b	Informant Contact Form	Attachment 6b- Informant Contact.pdf	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 135	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	135	-4,326	4,461
Annual IC Time Burden (Hours)	131	-4,311	4,442
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.